Heart-kidney Transplantation Research Articles

Continuous-flow left ventricular assist devices associated survival awaiting heart and heart-kidney transplant.

Improvement in continuous-flow left ventricular assist device (CF-LVAD) technology has translated to better outcomes for patients on CF-LVAD support as a bridge-to-transplant. However, data are lacking regarding the subset of CF-LVAD patients with renal failure awaiting simultaneous heart-kidney transplant (HKTx). We sought to better understand the characteristics and outcomes of patients in this group. The United Network for Organ Sharing (UNOS) database was used to identify adult patients listed for heart transplant (HTx) or HKTx from January 1, 2009 to March 31, 2017. Patients were followed from time on waitlist to either removal from waitlist or transplantation. Demographic and clinical data for HTx and HKTx patients were assessed. Kaplan-Meier analysis assessed waitlist and post-transplant survival. For waitlisted patients, both death and removal from the waitlist due to deteriorating medical condition were considered events. Overall, 26 638 patients registered for transplant were analyzed. 25 111 (94%) were listed for HTx, and 1527 (6%) for HKTx. 7683 (29%) patients listed for HTx had CF-LVAD support. For those listed for HKTx, 441 (28%) underwent dialysis alone, 256 (17%) had CF-LVAD support alone, and 85 (6%) were treated with both CF-LVAD and dialysis. 15 567 (58%) underwent HTx, and 621 (2%) underwent HKTx. In these groups, post-transplant survival was similar (p=0.06). Patients listed for HKTx treated with both dialysis and CF-LVAD had significantly worse waitlist survival compared to HKTx recipients (p < 0.001). Post-transplant survival is comparable between HTx and HKTx, and early survival is similar between HTx patients and those listed for HTx with CF-LVAD support. However, outcomes on the waitlist for HKTx in CF-LVAD patients on dialysis is significantly worse compared to HKTx recipients. This highlights the need to better account for this patient population when allocating organs.

Value of Renal Histology in Predicting Cardiorenal Outcomes in Heart Transplant-listed Patients.

We identified 18 patients with renal histology consistent with CRS from 655 consecutive heart transplant-listed patients between 2010 and 2019. Biopsies were analyzed for glomerular, tubular, interstitial, and arteriolar changes tallied to give a biopsy chronicity score. The primary outcome, MAKE, was a composite of death, need for renal replacement therapy (RRT), or estimated glomerular filtration rate decline >50%. These were evaluated at 2 time points: before and following the transplant. Secondary outcomes included the individual components of the composite outcomes and the need for short-term RRT following the transplant. The mean age was 52.3 y, 22% were female. Five patients did not survive to transplant. One patient underwent successful SHKT. MAKE occurred in 8 of 18 before the transplant and in 8 of 13 following the transplant. Neither outcome was predicted by baseline biochemistry. The biopsy chronicity score was significantly higher in patients with MAKE before transplant (4.3 versus 1.7, P = 0.024) and numerically higher in patients requiring short-term RRT following transplant (3.2 versus 0.7, P = 0.075). Contrary to limited previous literature, interstitial fibrosis did not predict any outcome, whereas tubular atrophy and arteriosclerosis were associated with MAKE before transplant. A higher biopsy chronicity score was associated with adverse kidney endpoints, raising its potential utility over standard biochemistry in considering SHKT referral.

634. Implementation of a medical education intervention to improve acceptance of HIV-positive donors for transplant at a tertiary care hospital

Abstract Background The HIV Organ Policy Equity Act (HOPE Act) was enacted in the US on November 21, 2013. HIV patients have a higher waitlist mortality and decreased access to transplant compared to HIV negative controls. The HIV Organ Policy Equity Act (HOPE Act) was a major step towards increasing the donor pool, but utilization of organs through the act has been less than initially anticipated.. Our own institution performed only one HIV D+/R+ transplant in the first four years of the trial despite a significant number of HIV+ patients on the waitlist. TableFigure summarizing perceived barriers and targeted interventions. Rate of HOPE transplants impacted positively by intervention Rate of HOPE transplants impacted positively by intervention Methods Monthly multidisciplinary meetings were set up. The agenda included discussing all offers, risks/benefits in a standardized format. Didactic sessions were conducted to address identified barriers to accepting HIV+ organs (Figure 1). HOPE consultants from experienced larger-volume centers were invited as guests. Results In the 15 months since this intervention was implemented, there have been 7 HIV D+/R+ transplants including a heart-kidney transplant. While the overall rate of transplant didn't change in a statistically significant way pre and post intervention for patients the rate of HOPE transplants increased significantly (Figure 2). Conclusion Making organs from HIV-positive donors available for donation does not mean they will be used. Intensive provider education can improve organ acceptance rates and help fulfill the promise of the HOPE act. Disclosures Vagish Hemmige, MD, Merck: Grant/Research Support.

Heart–kidney transplant versus heart transplant in the obese: a propensity-matched analysis

The decision to perform simultaneous heart-kidneytransplant (HKT) rather than isolated heart transplant (IHT) for patients with advanced kidney disease is challenging. Limited data exist to guide this decision in obese patients. We sought to compare mortality after HKT and IHT in obese patients with non-dialysis-dependent kidney disease. The United Network for Organ Sharing was queried for data on adult heart transplant recipients from 2000 to 2022. Inclusion criteria were obesity, estimated glomerular filtration rate <45 ml/min/1.73 m2 and no pretransplant dialysis. HKT and IHT recipients were propensity matched. Morbidity was compared using chi-squared, Fisher's exact and McNemar's tests. Survival was assessed with Kaplan-Meier estimation. Risk factors for mortality were examined with Cox regression. A total of 289 HKT and 1920 IHT recipients met inclusion criteria. Heart-kidney recipients had higher baseline creatinine and rates of intensive care unit disposition than IHT recipients (both standardized mean differences >0.10). Propensity matching resulted in 239 pairs of HKT and IHT recipients with minimal differences in baseline characteristics. Heart-kidney recipients had higher 5- and 10-year survival than IHT recipients on unmatched (77% vs 69%, P = 0.011 and 58% vs 48%, P = 0.008) and propensity matched analyses (77% vs 68%, P = 0.026 and 57% vs 39%, P = 0.007). Heart-kidney transplantation was protective against 10-year mortality on multivariable regression (hazard ratio 0.585, P = 0.002). In obese patients with non-dialysis-dependent kidney disease, HKT may decrease long-term mortality relative to IHT and should be strongly considered as a preferred treatment.

Simultaneous heart-kidney transplantation during mechanical circulatory support in a patient with bilateral iliac artery stenosis

Seonhwa Lee, Kyung Sub Song, Yun Seok Kim, Woo Sung Jang, Jae-Bum Kim, Nam-Hee Park, Woo Yeong Park, Ui Jun Park, Hyungseop Kim, In-Cheol Kim. Korean J Transplant 2022;36:87. https://doi.org/10.4285/ATW2022.F-2042

Abstract 14413: Possible Antibody Mediated Cardiac Rejection After Combined Heart-Kidney Transplant in a Sensitized Patient Associated to COVID-19 Pneumonia

Background: Antibody mediated rejection (AMR) starts with the appearance of donor-specific antibodies (DSA), followed by graft injury that may be subclinical and can progress to cardiac allograft vasculopathy (CAV) and chronic graft dysfunction. Case report A 48-year-old man with a past medical history of right nephrectomy due to congenital renal atrophy and dilated cardiomyopathy required heart transplantation at age 31, presented an episode of AMR grade 2 ten years post-transplant developing CAV with graft loss and end-stage renal disease. He was listed for a combined heart-kidney transplant. His panel reactive antibody (PRA) level was 40%, requiring desensitization therapy (plasmapheresis, intravenous gamma globulin and rituximab). At age 44, he received a heart-kidney transplant. Methylprednisolone and rabbit antithymocyte globulin were used for induction and desensitization therapy with plasmapheresis and intravenous gamma globulin at months 0-3-6-12 was continued. Maintenance immunosuppression therapy continued with tacrolimus, mycophenolic acid and prednisone. During follow-up persistent circulating DSA anti-class II HLA were detected and PRA reached 80%. He was admitted with a multifocal COVID-19 pneumonia. He had received 4 doses of the messenger RNA vaccine BNT162b2. Dexamethasone was started and mycophenolic acid was discontinued for 14 days. He did not need mechanical ventilation. Echocardiogram revealed marked concentric LVH, LVEF = 60%, grade II diastolic dysfunction and reduced global longitudinal strain (-7,6%). Pro-BNP was 962 pg/ml, and Troponin T 100 pg/ml. Endomyocardial biopsy showed no signs of cellular rejection nor capillary injury. Immunopathologic findings were negative. Coronary angiogram showed no significant lesions. AMR was suspected, the patient was treated with methylprednisolone, plasmapheresis and intravenous gamma globulin. Clinical response was satisfactory, and he was discharged in functional class I (NYHA). Conclusions Although both histological and immunopathologic studies were negative, clinical suspicion for AMR in a highly sensitized patient prevailed in the context of a recent infectious intercurrence. Other diagnosis cannot be completely ruled out in this clinical scenario.

Current considerations for heart-kidney transplantation.

Cardiorenal syndrome is a complex syndrome characterized by dysfunction of the heart and kidneys in an interdependent fashion and is further divided into different subtypes based on primary organ dysfunction. Simultaneous Heart-Kidney transplantation is the treatment of choice for end-stage irreversible dysfunction of both organs, however it may be avoided with determination of cardiorenal subtype and management of primary organ dysfunction. This article discusses types of cardiorenal syndrome, indications and concerns regarding the use of simultaneous heart-kidney transplantation, and outlines algorithms for determination of need for dual vs. single organ transplantation.

Severely Reduced Kidney Function Assessed by a Single eGFR Determination at the Time of an Isolated Heart Transplant Does Not Predict Inevitable Posttransplant ESKD.

Consensus guidelines advise simultaneous heart kidney transplantation (SHK) in heart candidates with an estimated glomerular filtration rate (eGFR) of <30 mL/min/1.73 m 2 . We hypothesize that a significant fraction of such patients would not need an SHK, even though a graded increase in mortality and end-stage kidney disease (ESKD) would be seen with decrements in eGFR. United Network of Organ Sharing data for isolated heart transplants between 2000 and 2020 were divided into two groups based on eGFR at transplant (≤20 mL/min/1.73 m 2 and 21-29 mL/min/1.73 m 2 ). The primary outcome was mortality and secondary outcome was ESKD posttransplant. Cox regression and cumulative incidence competing risk methods were used to compare risk of mortality and ESKD. There was no difference in mortality (adjusted hazard ratio [aHR] 0.82 [95% confidence interval, CI: 0.60-1.11, P = 0.21]) or ESKD (aHR 1.01 [95% CI: 0.49-2.09, P = 0.96]) between the two groups (≤20 versus 21-29). The overall incidence of ESKD for the entire cohort at 1, 5, and 10 y were 1.5%, 9.5%, and 20%. Although risk of ESKD is highest in heart candidates with an eGFR <30 mL/min/1.73 m 2 , <10% of patients reach ESKD within 5 y' and most will recover significant renal function posttransplant. More refined selection criteria are required to identify candidates for SHK.

Combined Heart-Kidney Transplantation: Indications, Outcomes, and Controversies.

Renal dysfunction, a prevalent comorbidity in advanced heart failure, is associated with significant morbidity and mortality after heart transplantation. In the recent era, the field of combined heart-kidney transplantation has experienced great success in the treatment of both renal and cardiac dysfunction in end-stage disease states, and the number of transplants has increased dramatically. In this review, we discuss appropriate indications and selection criteria, overall and organ-specific outcomes, and future perspectives in the field of combined heart-kidney transplantation.

Overcoming challenges in patient selection and monitoring in combined heart and kidney transplantation.

Combined heart-kidney transplantation (HKT) is a growing therapeutic strategy in patients with advanced heart failure (HF) and concomitant chronic kidney disease (CKD). Although patients with advanced HF and need for chronic haemodialysis have a clear indication for combined HKT, challenges to current practice lie in identifying those patients with severely depressed kidney function, which will not recover kidney function after restoration of appropriate haemodynamic conditions following heart transplantation (HT) alone. Because of the paucity of available organs, maximisation of kidney graft utility whilst minimising the operative risks associated with combined transplantation is mandatory. The benefits of HKT go beyond the mere restoration of kidney function. Data from registry analysis show that HKT improves overall survival in patients with CKD, as compared to heart transplant only, and it is associated with reduced incidence of heart allograft rejection, likely through the promotion of host immune tolerance mechanisms. In patients not requiring chronic dialysis, kidney-after-heart strategy may be explored, instead of combined HKT, in particular when the aetiology of CKD is unclear. This indeed allows for monitoring and gaging of indications for combined transplantation in the postoperative period. This approach however should be matched with priority listing for kidney transplantation given the high waitlist mortality in heart transplant recipients with associated CKD. The use of kidney machine perfusion may represent an additional tool to optimise the outcome of HKT, allowing more time to stabilise the patient after HT surgery.

Combined resection of thoracic and abdominal organ clusters: a series of 50 cases

Objective: To examine the technique and effect of combined thoracic and abdominal organ clusters resection. Methods: From February 2019 to August 2021, totally 50 cases of combined thoracoabdominal organ cluster resection were completed at Transplant Medical Center, the Second Affiliated Hospital of Guangxi Medical University from donation after brain death donors. There were 47 males and 3 females, aging (34.8±12.3) years (range: 5 to 55 years). The length of hospital stay(M(IQR)) was 4(4) days (range: 2 to 43 days), the length of tube time was 4(2) days (range: 1 to 43 days). Through the midsternal incision and the abdominal grand cross incision, the cold perfusion was performing simultaneously when the perfusion lines of each target organ was established respectively. The combined resection was performed with the diaphragm as the boundary and the organ cluster as the unit. The heart and lung were separated on site and sent to the transplant hospital, and the abdominal organ cluster was directly preserved and returned to our hospital for further separation and repair. Results: Totaly 21 hearts, 47 pairs of lungs, 49 livers, 47 pairs of kidneys and 11 pancreas were harvested by this surgical treatment. The resection time was (32.6±6.5) minutes (range: 19 to 50 minutes), with no hot ischemia time. There was no accidental injury that affected organ quality and function. Heart transplantation was performed in 17 cases, combined heart-kidney transplantation in 2 cases, double lung transplantation in 43 cases, single lung transplantation in 6 cases, liver transplantation in 41 cases, combined liver-pancreas-duodenal cluster transplantation in 1 case, combined liver-kidney transplantation in 3 cases, combined pancreas-kidney transplantation in 9 cases, and kidney transplantation in 74 cases. Conclusion: Simultaneous perfusion and combined resection of thoracic and abdominal organ clusters for donation after brain death donors are feasible and effective.

Heart Transplantation, Either Alone or Combined With Liver and Kidney, a Viable Treatment Option for Selected Patients With Severe Cardiac Amyloidosis.

Background.Heart transplantation in cardiac amyloidosis (CA) patients is possible and generally considered for transplantation if other organs are not affected. In this study, we aimed to describe and assess outcome in patients following heart transplantations at our CA referral center.Methods.We assessed all CA patients that had heart transplantations at our center between 2005 and 2018. Patients with New York Heart Association status 3 out of 4, with poor short-term prognosis due to heart failure, despite treatment, and without multiple myeloma, systemic disease, severe neuropathic/digestive comorbidities, cancer, or worsening infections were eligible for transplantation. Hearts were transplanted by bicaval technique. Standard induction and immunosuppressive therapies were used. Survival outcome of CA patients after transplantation was compared with recipients with nonamyloid pathologies in France.Results.Between 2005 and 2018, 23 CA patients had heart transplants: 17 (74%) had light chain (light chain amyloidosis [AL]) and 6 (26%) had hereditary transthyretin (hereditary transthyretin amyloidosis [ATTRv]) CA. Also, 13 (57%) were male, and the mean age at diagnosis was 56.5 y (range, 47.7–62.8). Among AL patients, 13 had heart-only and 5 had heart-kidney transplantations. Among ATTRv patients, 1 had heart-only and 5 had heart-liver transplantations. The 1-y survival rate after transplantation was 78%, 70% with AL, and 100% with ATTRv. At 2 y, 74% were alive: 65% with AL and 100% with ATTRv.Conclusion.After heart transplantation, French CA and nonamyloid patients have similar survival outcomes. Among CA patients, ATTRv patients have better prognosis than those with AL, possibly due to the combined heart-liver transplantation. Selected CA patients should be considered for heart transplantations.

Outcomes in Patients With LVADs Undergoing Simultaneous Heart-Kidney Transplantation

Multiple studies have shown better outcomes for simultaneous heart-kidney transplant (sHKT) than for isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable left ventricular assist devices (LVADs) have not been well studied. Patients with durable LVADs and stage 3 or higher CKD (eGFR < 60 mL/min/1.73 m2) undergoing iOHT or sHKT between 2008 and 2020 were identified from the United Network for Organ Sharing registry. A Kaplan-Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival rates. Multivariable modeling was used to identify risk-adjusted predictors of 1 year post-transplant mortality. We identified 4375 patients; 366 underwent sHKT, and 4009 underwent iOHT. The frequency of sHKT increased during the study period. The 1-year post-transplant survival rate was worse in patients after sHKT than in patients after iOHT (80.3% vs 88.3%; P < 0.001) and persisted up to 5 years post-transplant (P = 0.001). sHKT recipients were more likely to require dialysis after transplantation and had longer hospital lengths of stay (P < 0.001). Multivariable analysis showed that sHKT remained an independent risk factor for mortality at 1 year (OR 1.58; P = 0.002). sHKT is becoming more common in patients with durable LVADs. Compared with iOHT, patients with sHKTs have worse short- and long-term survival rates and are more likely to require post-transplant dialysis.

Temporary Left Ventricular Support Device as a Bridge to Heart-Liver or Heart-Kidney Transplant: Pushing the Boundaries of Temporary Support.

In patients with severe cardiogenic shock, temporary mechanical circulatory support has become a viable strategy to bridge patients to heart transplantation. However, end-stage heart failure is often associated with progressive organ dysfunction of the liver or kidney. This can require a dual organ transplant for definitive management (combined heart-liver [HL] or heart-kidney [HK] transplantation). We evaluated temporary mechanical support to bridge patients to HL or HK transplant at a single, high-volume center. All patients who underwent Impella 5.0 placement from January 2014 to October 2018 were identified. From this dataset, patients who underwent placement as a bridge to dual organ transplant were selected, as were those who underwent Impella as a bridge to isolated heart transplant. Over the 5 years of evaluation, 104 patients underwent Impella 5.0 placement. Of these, 14.3% (n = 15) were identified as potential dual organ recipients (11 HK, 4 HL). In total, 80% (12/15) successfully underwent dual organ transplant (8 HK, 4 HL), with a 1-year survival of 100% in both transplanted groups. Among patients undergoing Impella 5.0 placement as a bridge to isolated heart transplant (n = 33), 78.8% (26) were successfully bridged, and 1-year survival was 92% after transplantation. Impella 5.0 is a viable bridge to dual organ transplantation and should be considered as a management strategy in these complex patients at experienced institutions.

The experience of hereditary apolipoprotein A-I amyloidosis at the UK National Amyloidosis Centre

Introduction Hereditary apolipoprotein A-I (AApoAI) amyloidosis is a rare heterogeneous disease with variable age of onset and organ involvement. There are few series detailing the natural history and outcomes of solid organ transplantation across a range of causative APOA1 gene mutations. Methods We identified all patients with AApoAI amyloidosis who presented to the National Amyloidosis Centre (NAC) between 1986 and 2019. Results In total, 57 patients with 14 different APOA1 mutations were identified including 18 patients who underwent renal transplantation (5 combined liver-kidney (LKT) and 2 combined heart-kidney (HKT) transplants). Median age of presentation was 43 years and median time from presentation to referral was 3 (0–31 years). Involvement of the kidneys, liver and heart by amyloid was detected in 81%, 67% and 28% of patients, respectively. Renal amyloidosis was universal in association with the most commonly identified variant (Gly26Arg, n = 28). Across all variants, patients with renal amyloidosis had a median creatinine of 159 µmol/L and median urinary protein of 0.3 g/24 h at the time of diagnosis of AApoAI amyloidosis and median time from diagnosis to end-stage renal disease was 15.0 (95% CI: 10.0–20.0) years. Post-renal transplantation, median allograft survival was 22.0 (13.0–31.0) years. There was one early death following transplantation (infection-related at 2 months post-renal transplant) and no episodes of early rejection leading to graft failure. Liver transplantation led to regression of amyloid in all four cases in whom serial 123I-SAP scintigraphy was performed. Conclusions AApoAI amyloidosis is a slowly progressive disease that is challenging to diagnose. The outcomes of transplantation are encouraging and graft survival is excellent.

Predicting Post-Heart Transplant Composite Renal Outcome Risk in Adults: A Machine Learning Decision Tool

Predicting Post-Heart Transplant Composite Renal Outcome Risk in Adults: A Machine Learning Decision Tool

The Impact of the New UNOS Allocation System on Heart Kidney Recipients

Purpose In October 2018, the United Network for Organ Sharing (UNOS) updated the allocation system for adult heart transplants (HT). While data suggests equivalent outcomes among HT recipients before and after this change, its effect on heart kidney transplants (HKT) has not been investigated. Methods A retrospective analysis of adults in the UNOS database undergoing HT and HKT from 2015 - 2021 was performed. The population was divided into a before and after allocation change group. Univariate t-test and chi-square tests were used to compare the cohorts. Our primary outcome was the effect of this change on patient survival. We also examined the use of mechanical support prior to transplantation (Tx). Results 17,684 patients were included; 9,805 transplanted before the change and 7,879 after. Mean wait time for HT decreased from 255 to 187 days following change in allocation system (p < 0.001). HT patients in the prior system were more likely to have a left ventricular assist device (LVAD) before Tx than HT patients in the new system (51.3% v 35.7%, p < 0.001). Use of intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenator (ECMO) was higher in the group transplanted after the allocation change (IABP: 26.8% v 7.4%, p < 0.001 and ECMO: 4.9% v 0.8%, p < 0.001). The proportion of HKT increased following the change (8.5% vs 5.6%). Pre-management of HKT mirrored that seen in HT with more HKT recipients on LVAD support before than after the change (41.7% v 29.9%, p < 0.001). Utilization of IABP and ECMO was also higher in the group transplanted after the allocation change (IABP: 26.2% v 9.8%, p < 0.001 and ECMO: 5.8% v 1.3%, p < 0.001). Under the new system, survival was lower among HKT recipients compared to only HT recipients (mean 382 days vs 446 days); meanwhile there was no difference in survival between HKT and HT alone in the old system. Conclusion Following the change in the allocation system, a higher proportion of patients receiving HT and HKT were on ECMO and IABP support pre-Tx, while less patients were on LVAD support pre-Tx. We observed a decrease in survival among HKT recipients after the change. This may be due to higher acuity of the HKT group under the new system, or may demonstrate an impact of temporary mechanical support on survival. More detailed analysis is needed to determine factors that are influencing survival in this cohort. In October 2018, the United Network for Organ Sharing (UNOS) updated the allocation system for adult heart transplants (HT). While data suggests equivalent outcomes among HT recipients before and after this change, its effect on heart kidney transplants (HKT) has not been investigated. A retrospective analysis of adults in the UNOS database undergoing HT and HKT from 2015 - 2021 was performed. The population was divided into a before and after allocation change group. Univariate t-test and chi-square tests were used to compare the cohorts. Our primary outcome was the effect of this change on patient survival. We also examined the use of mechanical support prior to transplantation (Tx). 17,684 patients were included; 9,805 transplanted before the change and 7,879 after. Mean wait time for HT decreased from 255 to 187 days following change in allocation system (p < 0.001). HT patients in the prior system were more likely to have a left ventricular assist device (LVAD) before Tx than HT patients in the new system (51.3% v 35.7%, p < 0.001). Use of intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenator (ECMO) was higher in the group transplanted after the allocation change (IABP: 26.8% v 7.4%, p < 0.001 and ECMO: 4.9% v 0.8%, p < 0.001). The proportion of HKT increased following the change (8.5% vs 5.6%). Pre-management of HKT mirrored that seen in HT with more HKT recipients on LVAD support before than after the change (41.7% v 29.9%, p < 0.001). Utilization of IABP and ECMO was also higher in the group transplanted after the allocation change (IABP: 26.2% v 9.8%, p < 0.001 and ECMO: 5.8% v 1.3%, p < 0.001). Under the new system, survival was lower among HKT recipients compared to only HT recipients (mean 382 days vs 446 days); meanwhile there was no difference in survival between HKT and HT alone in the old system. Following the change in the allocation system, a higher proportion of patients receiving HT and HKT were on ECMO and IABP support pre-Tx, while less patients were on LVAD support pre-Tx. We observed a decrease in survival among HKT recipients after the change. This may be due to higher acuity of the HKT group under the new system, or may demonstrate an impact of temporary mechanical support on survival. More detailed analysis is needed to determine factors that are influencing survival in this cohort.

Outcomes of Combined Heart-Kidney Transplantation in Older Recipients

<h3>Purpose</h3> The upper limit of recipient age for combined heart-kidney transplantation (HKT) remains controversial. This study evaluated trends and outcomes of HKT in patients aged 65 years or older. <h3>Methods</h3> The United Network of Organ Sharing (UNOS) registry was used to identify patients undergoing combined HKT from 2005-2021. Patients were stratified by age at the time of transplantation: <65 and ≥65 years. The primary outcome was one-year mortality. Secondary outcomes included 90-day and 5-year mortality, postoperative new-onset dialysis, postoperative stroke, acute rejection prior to discharge, and rejection within one-year of HKT. Survival was compared using Kaplan-Meier analysis, and risk-adjustment for mortality was performed using Cox proportional hazards modeling. <h3>Results</h3> There was a significant annual increase in frequency of HKT in recipients aged ≥65 from 5.6% of all HKT recipients in 2005 to 23.7% in 2021 (<i>p</i> = 0.002). Of 2,022 patients undergoing HKT in the study period, 372 (18.40%) were aged 65 or older. Older HKT recipients were more likely to be male and white and fewer required dialysis prior to HKT compared to younger recipients. There were no differences between cohorts in unadjusted 90-day, 1-year, or 5-year survival in Kaplan-Meier analysis. These findings persisted after risk-adjustment, with an adjusted hazard for one-year mortality for age ≥65 of 0.91 (95% CI [0.63-1.29], <i>p</i> =0.572). When modeled as a continuous variable, increasing age was also not associated with one-year mortality (HR 1.01 (95% CI [1.00-1.02], <i>p</i> = 0.236) per year). There was a trend for patients aged ≥65 to more frequently require new-onset dialysis after HKT prior to discharge (11.56% vs 7.82%, <i>p</i> = 0.051). Stroke and rejection rates were comparable between groups. <h3>Conclusion</h3> Combined HKT is being performed more frequently in older recipients in the United States. Although viewed by many programs as a contraindication, advanced age of 65 years or older should not preclude HKT as similar outcomes can be achieved as compared to younger recipients.

Outcomes of Patients Undergoing Combined Heart-Kidney Transplantation with or without Prior Ventricular Assist Device

<h3>Purpose</h3> Both combined heart-kidney transplantation and ventricular assist devices (VAD) pose significant challenges including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart-kidney transplants with and without VADs would have equivalent survival. Our aim was to compare the survival of heart-kidney transplant recipients with and without prior VAD placement. <h3>Methods</h3> We retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart-kidney transplants. The heart-kidney transplant recipients were divided into two groups: those patients who had a VAD prior to transplantation and those who did not have a VAD prior to transplantation. We created a matched cohort of patients undergoing heart-kidney transplantation with or without prior VAD using 1:1 optimal propensity-score matching with preoperative variables. <h3>Results</h3> In the propensity-matched cohort, 399 patients (50%) underwent heart-kidney transplantation with prior VAD and 399 (50%) underwent heart-kidney transplantation without prior VAD. The estimated survival of heart-kidney recipients with prior VAD was 84.8% at one year, 81.2% at three years, and 75.3% at five years. The estimated survival of heart-kidney recipients without prior VAD was 88.7% at one year, 86.1% at three years, and 81.4% at five years. There was no statistically significant difference in the survival of heart-kidney transplant recipients with or without prior VAD at one year (p = 0.1; Figure 1), three years (p = 0.065), or five years (p = 0.05). <h3>Conclusion</h3> Despite the increased challenge of heart-kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those patients who underwent heart-kidney transplantation without previous VAD placement.

Outcomes Of Intermittent Hemodialysis During Support With Ventricular Assist Devices: A Potential Bridge To Heart/kidney Transplantation?

Introduction Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. Methods We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Results Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Conclusions Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF. Severe renal dysfunction is a contraindication for receiving ventricular assist devices (VADs). Hence, patients with end-stage heart failure (ESHF) and severe renal dysfunction who are not candidates for heart/kidney transplantation (HT/KT) may only be considered for either intermittent hemodialysis (IHD) or hospice. However, there is little evidence about the outcomes of patients with ESHF who are initiated on IHD after VAD implantation. We reviewed the medical charts of all patients in our center who received IHD after VAD implantation. We considered IHD <6-hour sessions 3-4 times weekly, excluding continuous renal replacement therapy (CRRT). Continuous variables were expressed in means and standard deviations, or medians and p25-p75, according to their distribution. Categorical variables were represented in absolute numbers and percentages. Eleven patients (54.1 [±9.9] years of age, 6 [54.6%] women, and 6 [54.6%] African American) underwent VAD implantation as destination therapy (40%) or bridge to transplant (60%) and received IHD. Seven (63.6%) of them received HeartMate II, whereas the other patients were supported with HVAD HeartWare, and HeartMate 3 systems. By the time of VAD implantation, nine (81.8%) patients had history of chronic kidney disease with a median GFR was 60 (45-60) mL/min/1.73 m2 and a mean creatinine was 1.2 (±0.4) mg/dL. The mean outpatient furosemide-dose equivalent prior VAD implantation was 106 (±59.7) mg/day. Ten patients started IHD prior to discharge after VAD placement with a median time from VAD implantation to initiation of IHD was 26 (17-50) days. Another patient was initiated on IHD as outpatient within a year after receiving a VAD. Eight (72.7%) patients died during a follow-up of 886.7 (±762.1) days after initiation of IHD with a median survival time of 838 days. Three patients were bridged to transplantation: 2 HT/KT, and 1 HT (recovered renal function). Details about the timeline of events can be found in Fig 1. Intermittent hemodialysis helped to bridge 2 VAD patients to HT/KT, and another to HT and recovery of renal function. Larger studies could provide valuable insight into this potential strategy to widen the options of advanced heart failure therapies for patients with ESHF.